Improving care coordination for each patient
Millennium’s Ambulatory Services Team is focused on primary care practice transformation, with a strong emphasis on creating Patient-Centered Medical Homes for primary care practices. The Team is improving the coordination of care for each patient by working with primary care practices along with key clinical partners and community-based organizations across Western New York.
We are working with primary care practices to improve the delivery of healthcare for each patient.
Primary Care Transformation/Patient-Centered Medical Homes
The Patient-Centered Medical Home (PCMH) is a patient primary care office that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.”
Medical Homes work because:
They lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.
The PCMH model can create greater value for patients, providers and payers. Patients are given better access to care that is coordinated.
Because of this, many factors that drive up costs such as emergency department visits and in-patient hospitalizations are reduced.
The National Committee for Quality Assurance (NCQA) has recognized the Patient-Centered Medical Home (PCMH) as the most widely-used way to transform primary care practices into Medical Homes.
Health Homes provide Free community care management services to Medicaid recipients to help ensure their medical, mental health, and substance abuse treatment needs are being met.
Health Home enrollees received a dedicated Care Manager who oversees and provides access to all services an individual needs to stay healthy, out of the emergency room and out of the hospital.
- Develop patient’s personalized care plan.
- Make sure everyone involved in patient’s care.
- Understands patient’s goals.
- Encourage activities that keep the patient healthy.
- Assist the patient with housing, legal assistance, food and other essential needs.
- Help with better coordination of patient care.
We Are Creating Change…
By helping practices across Western New York attain PCMH 2014 Level National Committee Quality Assurance (NCQA) Recognition – the Gold Standard for practice Transformation.
By partnering with the University at Buffalo School of Nursing and the Greater Buffalo United Ministries to implement Million Hearts®, a national initiative with an ambitious goal to prevent 1 million heart attacks and strokes by 2017.
Million Hearts® is one element of Millennium’s Cardiovascular Health project which seeks to support implementation of evidence-based best practices for disease management in medical practices for adults with cardiovascular conditions.
In addition to blood pressure screenings administered by the UB Nursing students, participants also have an opportunity to visit additional “Health Stations” focused on Personal Health History, Vital Numbers, Nutrition, Exercise and Health Insurance options.
By supporting the mission of HEALTHeLINK to create and maintain a secure and reliable infrastructure for the timely and accurate electronic exchange of clinical information among health care providers and others involved in the delivery of health care services in Western New York and who are connected via State Health Information Network of New York (SHIN-NY). HEALTHeLINK will limit the duplication, control health care costs and improve the delivery of services, clinical outcomes and patient safety.
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